C-spine Imaging Research Articles

Performance improvement and patient safety program-guided quality improvement initiatives can significantly reduce computed tomography imaging in pediatric trauma patients.

Morbidity and mortality of cervical spine (C-spine) injury in pediatric trauma patients are high, necessitating quick and accurate diagnosis. Best practices emphasize minimizing radiation exposure through decreased reliance on computed tomography (CT), instead using clinical assessment, physical examination, and alternate imaging techniques. We implemented an institutional performance improvement and patient safety (PIPS) program initiative for C-spine clearance in 2010 because of high rates of CT scans among pediatric trauma patients. A retrospective review of pediatric trauma patients, aged 0 years to 14 years, in the pre- and post-PIPS implementation periods was conducted. Rates of C-spine CT, overall CT, other imaging modalities, radiation exposure, patient characteristics, and injury severity were compared, and compliance with PIPS protocol was reviewed. Patient characteristics and injury severity were similar before and after PIPS implementation. C-spine CT rates decreased significantly between groups (30% vs. 13%, p < 0.001), whereas C-spine plain x-ray rates increased significantly (7% vs. 25%, p < 0.001). There was no difference in C-spine magnetic resonance imaging between groups (12% vs. 10%, p = 0.11). In 2007, 71% of patients received a CT scan for any reason. However, the overall CT rate decreased significantly between groups (60% vs. 45%, p < 0.001). There was an estimated 22% decrease in lifetime attributable risk (LAR) for any cancer due to ionizing imaging exposure in males and 38% decrease in females between the pre- and post-PIPS groups. There was a 54% decrease in LAR for thyroid cancer in males and females between groups; 2014 compliance with the protocol was excellent (82-90% per quarter). Performance improvement and patient safety program-generated protocol can significantly decrease ionizing radiation exposure. We demonstrate that a simple protocol focused on C-spine imaging has high compliance, decreased C-spine CT scans, and decreased LAR for thyroid cancer. A secondary benefit is a reduction in total CT imaging, with an associated decrease in LAR for all cancers. Therapeutic study, level IV; diagnostic study, level III.

Imaging in the NEXUS-negative patient: when we break the rule

BackgroundIn spite of general acceptance and validation of NEXUS (National Emergency X-Radiography Utilization Study) in the clearance of cervical spine (C-spine) immobilized patients, clinicians often elect to image NEXUS-negative patients in clinical practice. ObjectivesWe sought to determine which variables (patient age, mechanism of injury, provider level of training, provider self-reported motivation) contribute to the decision of emergency medicine providers to image NEXUS-negative patients. MethodsThis is a prospective observational study of patients with blunt trauma and risk for C-spine injury who did not meet “trauma team activation” criteria. Providers at one high-volume emergency department (ED) prospectively recorded NEXUS criteria, as well as rationale for imaging NEXUS-negative patients. Researchers then retrospectively queried the electronic medical record for patient age, mechanism of injury, and results of diagnostic imaging. Study data were analyzed with χ2 and descriptive statistics. ResultsThree hundred patients were enrolled; 169 patients received C-spine imaging, of whom 53 were NEXUS-negative. There was no difference in imaging of NEXUS-negative patients as a factor of medical provider level of training (P=0.42). Of NEXUS-negative patients receiving imaging, 51 (96%) were older than 65 years, and 52 were being evaluated for a fall on level ground. Imaging revealed 7 positive findings. Two of these injuries were in NEXUS-negative patients. ConclusionRegardless of level of training, providers in our ED often imaged patients who met NEXUS low-risk criteria. This was mot common in geriatric patients who presented after falls. This digression from NEXUS led to the diagnosis of significant injuries in 2 patients which would otherwise have been missed.

Ceiling fan head injury to children in an Australian tropical location

To explore clinical aspects of head injuries caused by ceiling fans in children. Cases were identified using a sensitive search strategy of the Townsville Emergency Department information system from 1 December 2005 to 30 April 2010, and a retrospective structured medical record review was undertaken. During the study period there were 136 presentations with relevant injuries, with a higher incidence in the warmer months. There were three common mechanisms; those related to ingress and egress from bunk beds, children lifted by an adult, and children jumping from a piece of furniture. Aside from lacerations, the majority of children had unremarkable history and examination findings. There were 29 Computed Tomography (CT) scans of the head performed, four skull X-rays and no c-spine imaging. Forty-six children received sedation or anaesthesia as part of their management, 38 in the Emergency Department and eight in the operating theatre. Seven children sustained skull fractures and a total of 13 children were admitted to hospital for an average length of stay of 2.3 days. Ceiling fans are a small but important source of paediatric head injury in tropical Australia. Significant injuries are possible with 5% of patients having a positive finding on CT scan. Most fractures are palpable, CT is recommended if fracture cannot be confidently excluded clinically.

The NEXUS criteria

The National Emergency X-ray Utilisation Study (NEXUS) criteria and the Canadian cervical spine rules are validated clinical decision-making tools used to facilitate selective cervical spine (C-spine) radiography. The NEXUS criteria are frequently used, as the Canadian cervical spine rules have been noted to be difficult to learn, remember and implement. We present a series of significant C-spine injury in three elderly patients who would not have warranted C-spine imaging using the NEXUS criteria. Each patient was mobile and fully orientated after the injury. There was no midline tenderness, neurological deficit, distracting injury or alcohol/drug involvement. Plain film imaging was initially performed as each patient had a reduced range of movement. Significant odontoid peg injury was confirmed on subsequent computed tomography/MRI imaging for all patients. Despite previous validation studies of the NEXUS criteria in the elderly population, we would urge caution in using the NEXUS criteria alone in determining radiography of the C-spine in the elderly.

Evaluation of Distracting Pain and Clinical Judgment in Cervical Spine Clearance of Trauma Patients

The concept of distracting pain (DP) is a controversial subjective confounder that often impedes the efficient and timely clearance of the cervical spine (C-spine). This study attempted to define DP more objectively and assess its true potential to mask the presence of C-spine injury. It also evaluated reliability and safety of clinical judgment in discounting the significance of pain peripheral to the neck (PP). This prospective study included patients with a Glasgow Coma Score ≥14 at a level I trauma center presenting in a C-spine collar. Demographics, mechanism of injury, severity and location of all pain, and C-spine imaging data were obtained. Patient and examiner perception of DP were ascertained using the Verbal Numerical Rating Scale (VNRS) along with the examiner's clinical opinion as to the presence of a fracture. A total of 160 patients were studied: 65 % male, mean age 39 years, and 44 % presenting after a motor vehicle crash. In all, 16 % complained of neck pain (NP) and 82 % of PP. There were 134 patients without NP, 110 of whom (82 %) had PP. The mean VNRS in patients with no NP was 4.2; in patients with NP it was 4.8. When examined, 14 patients without NP exhibited posterior cervical tenderness, one of whom had a fracture (7 %). Of the patients with PP, 10 % stated it was DP. The mean VNRS described as DP by all patients was 7.5 but by clinician 6.5. VNRS described as not DP was 4.8 for both patients and clinicians. Overall, 8 of the 160 patients (5 %) had confirmed C-spine injuries. Regardless of NP or PP and its potentially distracting nature, clinicians believed no fracture was present in 95 % of all cases. Clinical impression was 98 % accurate. For patients with NP, clinical impression had a 91 % negative predictive value (NPV) and a 100 % a positive predictive value (PPV). In those without NP, the NPV was 99 % and the PPV 25 %. The concept of DP is subjective and unreliable as a method to mitigate missed C-spine injuries. If it is to be considered for use, DP should be defined as VNRS ≥5. Reliance on clinical impressions regardless of the presence or absence of NP or PP, distracting or otherwise, is accurate and safe.

Trauma CT scanning at University Hospital Coventry (UHCW): a retrospective review

s / Clinical Radiology 67 (2012) S11–S20 S19 How well do we image the c-spine in trauma? Authors: Mark Rodrigues, Emily R. McCall-Smith, Fergus J. Perks Background to the audit: Cervical spine (c-spine) trauma requires accurate assessment. Standard, indicator and target: Adequate x-rays require a lateral showing C1/C2 & C7/T1, AP showing C1-C7 & PEG view. If the films are inadequate, extra views CT should be performed. C-spine Imaging should be adequate in all trauma patients who require it. Methodology: Retrospective review of patients having c-spine films for trauma in Royal Infirmary of Edinburgh's AE urgent and emergency cases Authors: John Tuckett, Michael McNeill, Lance Cope Background to the audit: The Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER) states: “The employer shall ensure that a clinical evaluation of the outcome of each medical exposure is carried out and recorded” This is interpreted by our trust as: Each individual examination shall have a written evaluation (report) recorded in the patient's record at a time when the evaluation will influence the management of the patient Standard, indicator and target: 100% of A&E, orthopaedic and inpatient plain film examinations will have a written evaluation (report) recorded in the notes by the clinician at a time when the evaluation will influence the management of the patient. Methodology: Retrospective study of 4 departments (A&E, orthopaedic outpatients, EAU day shift, EAU night shift) over 5 days. 5 examinations from each department assessed each day. Notes were reviewed to see if clinicians entered a timely report. Results of 1st audit round: 79 examinations studied. 100% of A+E examinations, 80% of orthopaedic outpatient examinations, 59% of EAU day shift examinations and 83% of EAU night shift examinations had an opinion recorded in the notes in accordance with the above standard. 1st action plan: Audit findings were presented to orthopaedics and EAU and findings circulated to all clinicians. We impressed on the clinicians the need to record an X-ray interpretation in the notes when it is not timely to await the formal report. Results of 2nd round: Will be available at time of presentation.

Can cervical spine computed tomography assist in detecting occult pneumothoraces?

Introduction Screening CT often detects posttraumatic pneumothoraces that were not diagnosed on a preceding supine anteroposterior chest radiograph (occult pneumothoraces (OPTXs)). Because abdominal CT imaging misses OPTXs in the upper thorax, the objective of this study was to evaluate the utility of cervical spine (C-spine) CT screening for diagnosing OPTXs. Methods A dual-institution (Foothills Medical Centre and Grady Memorial Hospital) retrospective review of consecutive OPTXs was performed. The accuracy of various CT screening protocols in detecting OPTXs was compared. Results OPTXs were detected in 75 patients. Patient demographics and injury characteristics were similar between centres (65% male; 97% blunt mechanism; 29% hemodynamically unstable; mean ISS = 27; mean length of stay = 22 days; mortality = 9%)( p > 0.05). Patients received either abdominal (41%) or thoraco-abdominal (59%) CT imaging. Most patients (89%) also underwent C-spine CT imaging. OPTXs were evident on thoracic CT in 100% (44/44), abdominal CT in 83% (62/75), and C-spine CT in 82% (55/67) of cases. All patients with OPTXs identified solely on thoracic CT (i.e. not abdominal) who also underwent imaging of their C-spine could have had their OTPXs diagnosed by using the pulmonary windows setting of their C-spine CT series. Combining C-spine and abdominal CT screening diagnosed all OPTXs (67/67) detected on thoracic CT, for patients who also underwent these investigations. Conclusions OPTXs were evident on thoracic (and not abdominal) CT in 17% of severely injured patients. For patients who also underwent C-spine imaging, all OPTXs isolated to thoracic CT could be diagnosed by using the pulmonary windows setting of their C-spine CT imaging protocol. All OPTXs, regardless of intra-thoracic location, could also be detected by combining C-spine and abdominal CT screening.

The Presence of Nonthoracic Distracting Injuries Does Not Affect the Initial Clinical Examination of the Cervical Spine in Evaluable Blunt Trauma Patients: A Prospective Observational Study

A distracting injury mandates cervical spine (c-spine) imaging in the evaluable blunt trauma patient who demonstrates no pain or tenderness over the c-spine. The purpose of this study was to examine which distracting injuries can negatively affect the sensitivity of the standard clinical examination of the c-spine. This is a prospective observational study conducted at a Level I Trauma Center from January 1, 2008, to December 31, 2009. After institutional review board approval, all evaluable (Glasgow Coma Scale score ≥13) blunt trauma patients older than 16 years sustaining a c-spine injury were enrolled. A distracting injury was defined as any immediately evident bony or soft tissue injury or a complaint of non-c-spine pain whether or not an actual injury was subsequently diagnosed. Information regarding the initial clinical examination and the presence of a distracting injury was collected from the senior resident or attending trauma surgeon involved in the initial management. During the study period, 101 evaluable patients sustained a c-spine injury. Distracting injuries were present in 88 patients (87.1%). The most common was rib fracture (21.6%), followed by lower extremity fracture (20.5%) and upper extremity fracture (12.5%). Only four (4.0%) patients had no pain or tenderness on the initial examination of the c-spine. All four patients had bruising and tenderness to the upper anterior chest. None of these four patients developed neurologic sequelae or required a surgical stabilization or immobilization. C-spine imaging may not be required in the evaluable blunt trauma patient despite distracting injuries in any body regions that do not involve the upper chest. Further definition of distracting injuries is mandated to avoid unnecessary utilization of resources and to reduce the imaging burden associated with the evaluation of the c-spine.

Frequent Computed Tomography Scanning Due to Incomplete Three-View X-Ray Imaging of the Cervical Spine

Conventional C-spine imaging (3-view series) is still widely used in trauma patients, although the utilization of computed tomography (CT) scanning is increasing. The aim of this study was to analyze the value of conventional radiography and the frequency of subsequent CT scanning due to incompleteness of three-view series of the C-spine in adult blunt trauma patients. We analyzed the data of a prospectively collected database including all patients between November 2005 and November 2007 treated in the trauma resuscitating room. We assessed the reasons for subsequent CT scanning after the three-view series according to the following classification: inevaluability, incompletion, evaluation of findings on three-view series or evaluation of unexplained, and persistent clinical symptoms. Furthermore, we evaluated possible predictors for incompleteness. Of 1,283 blunt trauma patients, 88 C-spine injuries were diagnosed with an overall incidence of 6.9%. One hundred fifty-nine patients (12%) had their C-spine cleared based on the NEXUS criteria and 12 died before C-spine imaging could be performed. A total of 717 patients were primarily evaluated with three-view series and 395 patients primarily with CT scanning. Within the population with primarily three-view series, 249 (35%) were repeatedly incomplete and 16 (2%) were inevaluable. In the majority of the incomplete three-view series, no apparent reason could be determined. However, the presence of clavicular fractures (resulting in incomplete radiographs in 68% vs. 34% without a fracture; p < 0.001) and rib fractures (56% vs. 34%; p = 0.008) were associated with incomplete three-view series. In more than one third of the patients primarily assessed with three-view X-ray series of the C-spine, the results are incomplete or inevaluable necessitating CT scanning. Although the majority of the incomplete series remain unexplained, we advise CT scanning in patients having clavicular and rib fractures because this increases the likelihood of obtaining incomplete three-view series.

Canadian C-spine Rule and the National Emergency X-Radiography Utilization Low-Risk Criteria for C-spine radiography in young trauma patients

Purpose The Canadian C-spine (cervical spine) Rule (CCR) and the National Emergency X-Radiography Utilization Low-Risk Criteria (NLC) are criteria designed to guide C-spine radiography in trauma patients. It is unclear how these 2 rules compare with young children. Methods This study retrospectively examined case-matched trauma patients 10 years or younger. Two cohorts were identified—cohort A where C-spine imaging was performed and cohort B where no imaging was conducted. The CCR and NLC criteria were then applied retrospectively to each cohort. Results Cohort A contained 125 cases and cohort B with 250 cases. Seven patients (3%) had significant C-spine injuries. In cohort A, NLC criteria could be applied in 108 (86.4%) of 125 and CCR in 109 (87.2%) of 125. National Emergency X-Radiography Utilization Low-Risk Criteria suggested that 70 (58.3%) cases required C-spine imaging compared to 93 (76.2%) by CCR. National Emergency X-Radiography Utilization Low-Risk Criteria missed 3 C-spine injuries, and CCR missed one. In cohort B, NLC criteria could be applied in 132 (88%) of 150 and CCR in 131 (87.3%) of 150. The NLC criteria identified 8 cases and CCR identified 13 cases that would need C-spine radiographs. Fisher's 2-sided Exact test demonstrated that CCR and NLC predictions were significantly different ( P = .002) in both cohorts. The sensitivity of CCR was 86% and specificity was 94%, and the NLC had a sensitivity of 43% and a specificity of 96%. Conclusions Although CCR and NLC criteria may reduce the need for C-spine imaging in children 10 years and younger; they are not sensitive or specific enough to be used as currently designed.

New Rule for C-Spine Imaging in Children Younger Than 3 Years

Cervical spine injury is uncommon in toddlers, but clinical clearance is purported to be unreliable in this age group. The NEXUS and Canadian C-Spine Rule studies included too few infants and toddlers to render either decision rule valid in these age groups. These authors studied data from 22 level I or II trauma centers in the U.S., Canada, and Brazil during a …